Provider Demographics
NPI:1881624146
Name:RIDGEWAY, JOHN B (LLP LMSW CAAC SAP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:B
Last Name:RIDGEWAY
Suffix:
Gender:M
Credentials:LLP LMSW CAAC SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G 4511 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1107
Mailing Address - Country:US
Mailing Address - Phone:810-720-0640
Mailing Address - Fax:810-720-0640
Practice Address - Street 1:G 4511 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1107
Practice Address - Country:US
Practice Address - Phone:810-720-0640
Practice Address - Fax:810-720-0640
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICAC-I,SAP101YA0400X
MI6301003780103TC0700X
MI68010130861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP29810001Medicare PIN